Ambrosio Guillen Texas State Veterans Home

Name: Ambrosio Guillen Texas State Veterans Home
Address: 9650 Kenworthy St, El Paso, TX, 79924, US
Telephone: 9157510967

9650 Kenworthy St, El Paso, TX 79924 · El Paso County · 160 certified beds · avg 152 residents/day · certified since Aug 3, 2005

Part of chain: TEXVET (9 facilities, chain avg rating 2.7★)

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.45

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (43)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 9, 2026	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 9, 2026	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 19, 2026	E · Potential for harm, repeated	The facility did not keep residents' personal and medical information private and confidential. · from a complaint
Mar 19, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Feb 3, 2026	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Feb 3, 2026	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Feb 3, 2026	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Sep 15, 2025	E · Potential for harm, repeated	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Sep 15, 2025	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 15, 2025	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Sep 15, 2025	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Apr 3, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 31, 2025	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jan 31, 2025	E · Potential for harm, repeated	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Jan 31, 2025	E · Potential for harm, repeated	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jan 31, 2025	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 31, 2025	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jan 31, 2025	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jan 31, 2025	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Nov 18, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jul 26, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Jul 26, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Jul 26, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
May 31, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
May 31, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Apr 24, 2024	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Dec 1, 2023	E · Potential for harm, repeated	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Dec 1, 2023	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Dec 1, 2023	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Dec 1, 2023	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Dec 1, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Dec 1, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Dec 1, 2023	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint
Dec 1, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Dec 1, 2023	D · Potential for harm, one-off	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Dec 1, 2023	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (7 → 8).

Year	Citations	Worst severity that year
2023	10	E
2024	7	D
2025	13	E
2026	13	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.45	3.46	3.95	top 8% in Texas; top 25% in the U.S.
Registered Nurse hours	0.55	0.44	0.69	top 20% in Texas; bottom 46% in the U.S.
Weekend total nurse staffing	3.90	3.04	3.50	top 8% in Texas; top 26% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.34	0.34	0.48	top 36% in Texas; bottom 41% in the U.S.
Total nursing staff turnover (%)	39.7	55.3	45.8	top 20% in Texas; top 35% in the U.S.
RN turnover (%)	42.9	54.6	42.9	top 35% in Texas; bottom 49% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.71, RN 0.46, weekend 3.26. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Berkely, John	Individual	W-2 Managing Employee	NOT APPLICABLE	03/01/2018
Biggs, William	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2018
Care Inns of Texas-Temple LTD	Organization	Operational/Managerial Control	NOT APPLICABLE	03/01/2018
Elledge, Matthew	Individual	W-2 Managing Employee	NOT APPLICABLE	12/31/2017
McBride, Michael	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2018
McCrary, Janice	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2018
McLemore, William	Individual	W-2 Managing Employee	NOT APPLICABLE	10/16/2014
McLemore, William	Individual	Corporate Officer	NOT APPLICABLE	12/16/2014
McLemore, William	Individual	Operational/Managerial Control	NOT APPLICABLE	12/05/2014
Texas Vsi, LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	03/01/2018
Touchstone Veterans Management, LTD	Organization	Operational/Managerial Control	NOT APPLICABLE	12/05/2014

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Avir at Patriot	2.6 mi	El Paso, TX	★☆☆☆☆	1/5
Los Arcos Del Norte Care Center	3.1 mi	El Paso, TX	★☆☆☆☆	2/5
Mountain Villa Nursing Home	6.1 mi	El Paso, TX	★★★★☆	4/5
Nazareth Living Care Center	7.0 mi	El Paso, TX	★★☆☆☆	2/5
Mountain View Health & Rehabilitation	8.1 mi	El Paso, TX	★☆☆☆☆	1/5
Grace Pointe Wellness Center	8.1 mi	El Paso, TX	★☆☆☆☆	1/5
Franklin Heights Nursing & Rehabilitation	8.1 mi	El Paso, TX	★☆☆☆☆	1/5
White Acres Wellness & Rehabilitation	8.2 mi	El Paso, TX	★★☆☆☆	2/5
Avir at el Paso	8.2 mi	El Paso, TX	★★☆☆☆	1/5
St. Teresa Nursing & Rehab Center	8.3 mi	El Paso, TX	★☆☆☆☆	2/5
The Bartlett Skilled Nursing and Assisted Living	8.8 mi	El Paso, TX	★☆☆☆☆	2/5	abuse
Edgemere Estates	9.3 mi	El Paso, TX	★☆☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in El Paso →

Facility data as of CMS processing date 2026-08-01. CCN 676060.

The Care File

Visit checklist — Ambrosio Guillen Texas State Veterans Home

9650 Kenworthy St, El Paso, TX 79924 · 9157510967

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $0

Questions for the administrator:

☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 676060 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)